Impact of socioeconomic status on postoperative complications and revision rates in free flap breast reconstruction.

Abstract

Socioeconomic status (SES) can predict postoperative outcomes in some specialties, but its influence on autologous breast reconstruction is yet to be defined. We examined the impact of SES on postoperative complications and esthetic revisions in free flap breast reconstruction. This was a retrospective single-center review of consecutive patients who underwent free flap breast reconstruction between 2013 and 2023. Surgical outcomes, time from mastectomy to reconstruction, and rates of esthetic revision were analyzed while considering race, insurance status, and SES variables, including United States Census data and the Neighborhood Atlas Area Deprivation Index (ADI). Overall, 244 patients underwent 375 free flap (113 unilateral, 30%) procedures. Significant racial differences included higher body mass index, higher prevalence of diabetes and tobacco use (p < 0.05), and disadvantaged SES, including higher ADI, food insecurity, and limited vehicle access (p < 0.05). Non-White patients waited longer for free flap reconstruction and had fewer flap revisions (p < 0.05). Medicaid insurance predicted complete flap loss (odds ratio (OR) 6.981, 95% confidence interval (CI) 1.244-39.168, p < 0.05). On multivariate analysis, non-White race (OR 0.417, 95% CI 0.189-0.644, p < 0.05), ADI (OR 0.983, 95% CI 0.969-0.998, p < 0.05), and higher number of comorbidities (OR 0.704, 95% CI 0.565-0.859, p < 0.05) negatively predicted esthetic revisions (p < 0.05). Our results suggest disadvantaged SES does not impact free flap complication rates but may influence surgical timing and whether patients undergo elective flap revisions. Identifying these obstacles is an important step toward improving access to free flap breast reconstruction.